Mitral valve surgery with extensive annular calcification: review of surgical techniques and postoperative complications

Mitral annular calcification (MAC) represents an important risk factor in mitral valve (MV) surgery. Despite several procedures having been described, no surgical treatment of choice has been established so far: whether a decalcification should be systematically carried out, or if the MV should be preferentially repaired rather than replaced. A review of the literature on patients undergoing MV surgery associated with MAC was performed. Studies were excluded if dealing with endovascular procedures or emergency surgery for associated endocarditis. Case reports were also not considered in the final analysis. The literature search identified 1429 potentially eligible studies, and 25 papers were eventually included. Several surgical techniques were described to approach this challenging condition. During MV surgery, the presence of MAC favors the occurrence of suboptimal intraoperative outcomes. MAC-related complications such as atrioventricular groove rupture, cerebrovascular accident, new permanent pacemaker implantation, intraoperative conversion from valve repair to replacement and mortality were analyzed. MV surgery in the presence of MAC considerably impacts the postoperative outcomes in terms of morbidity and mortality. A great variability of surgical techniques is reported, suggesting the need for standardization of the approach.